Mindful Staff Boosts Hospital Profits

HARVARD UNIVERSITY  

 PSYC E-1609 

The Neuroscience of Learning: An Introduction to Mind, Brain, Health and Education 

Mindful Staff Boosts Hospital Profits 

 By

Kim Byrd-Rider  

2/8/2018 

TABLE OF CONTENTS 

​​Introduction 3 

​Background 3 

​The Problem 5 

​Research Question 6 

​Literature Review 6 

​Literature Genres 6 

​Hospital Finances        7 

​Mindful Definitions   14 

​Mindful Programs and Mental Effects   15 

​Mindful Programs and the Brain     19 

​Mindful Programs and Physical Health Effects   2 

​Mindful Programs and Education Effects   27 

​Methodology                         30 

​Analysis 31 

​ Conclusions 37 

​   Limitations of the Study and Recommendations for Future Studies 37 

​Answer to the Research Question 37 

​General Summary 38 

​References 40.7​ 

Introduction 

The hospital sustainability crisis is unique. In an age of accelerating hospital closures due to an inability to financially sustain themselves (Hsia & Shen, 2011), a shining star of fiduciary hope exists: mindful awareness and mindful concentration for hospital staff education (Hyland & Mills, 2015; Van Dongen, Van Berkel, Boot, Bosmans, Proper, Bonges, & Van Wier, 2016). Typically, businesses turn to the accounting department to begin cutting expenditures and adding revenue building departments when in crisis.  

Hospitals are scored according to the quality of their patient care via patient reports gathered by insurance companies (Garthwaite, Gross, & Notowidigdo, 2018). Hospital insurance reimbursements are susceptible to patient quality care scores, which are a result of how the hospital staff treat the hospital patients and their families/visitors (Garthwaite, Gross, & Notowidigdo, 2018). Low scores equal lower reimbursements, causing some hospitals to close. Making matters worse, when a hospital closes due to finances, the number of uninsured patients rises in the neighboring hospitals, increasing their odds of facing closures as well (Garthwaite, Gross, & Notowidigdo, 2018). The following literature review evaluates mindful staff programs through mind, brain, health and education solutions to potentially improve staff well-being and performance, increasing patient quality care and aid in hospitals’ financial stability. 

Background 

Many hospital employees operate under some level of post-traumatic stress disorder (PTSD) due to their hospital job. An average of 40% of U.S. nurses meet the diagnostic criteria for PTSD (Mealer, Burnham, Goode, Rothbaum, & Moss, 2009). Long-hours, under-staffing and poor stress coping skills escalate job burnout, fatigue and poor health, which are ever-present risk factors prohibiting hospital staff from producing quality patient care (Mealer, et al., 2009). Hospital employees experience the third largest amount of workplace violence in the nation (King, Angstadt, Sripada, & Liberzon, 2017). Hospital staff receive 10% of all workplace verbal and physical abuse (King, et al., 2017). Workplace violence affects job performance, job productivity, job moral, job retention and job satisfaction (King, et al., 2017). As an example of the amount and kind of stressors hospital staff undergo in one year, a study by Speroni and colleagues (2014) explains that 76% of hospital nurses experience violence with emergency nurses at 88.1%. The perpetrators were primarily 26-35-year-old white makes who were confused or influenced by drugs or alcohol (Speroni, Fitch, Dawson, Dugan, & Atherton, 2014). Events such as shouting, swearing, grabbing, scratching and kicking occur. Physical abuse to nurses averages 29.9% from patients and 3.5% from visitors (Speroni, Fitch, Dawson, Dugan, & Atherton, 2014). 

Reported abuses are believed to be under-reported due to hospital employee justifications for their patients’ and visitors’ behavior (King, et al., 2017). The stressed relationship problem between the staff and the patients/visitors ultimately fans out into a financial drain for the hospital with a loss of quality-based insurance reimbursements (Garthwaite, Gross, & Notowidigdo, 2018).  

Poor staff to patient/visitor treatment compounds the trauma of a dire hospital visit for patients and their families/visitors. How to improve hospital staff performance has been poorly explored by the research literature but how to improve general job performance has been researched. Potential hospital financial sustainability may come in the form of a trans-disciplinary approach of mind, brain, health and education for a mindful hospital program.  

The Problem 

Hospital staff continue to work with poor mental and physical health with no resolution in sight (Mealer, 2009), to the detriment of hospital sustainability. A plethora of research has been focused on mindful techniques (Van Dam, van Vugt, Vago, Schmalzl, Saron, Olendzki, ... & Fox, 2018) with little application to hospital work settings (Duggan & Julliard, 2018). The problem is that there is a gap in the literature that provides sufficient evidence to support large-scale implementation of this practice.  

Compounding the hospital staff well-being problem, insurance companies mandate quality measurement systems. Programs such as value-based purchasing for federal insurance incentives pay hospitals for quality patient care (Barnes, Oner, Ray, & Zengul, 2018). Pay for performance is a system where the amount of insurance payments for services is congruent with measurable positive patient outcomes (Barnes, et al. 2018). Also, accountable care organizations are forming among doctors and hospitals where high quality care and wise spending provide sharing the savings with insurance companies (Barnes, et al., 2018). These are just a few quality care reimbursement tools implemented by federal and private insurance companies which increase or decrease hospital reimbursements (Barnes, et al., 2018). Hospitals also get punished financially for not producing quality patient care. Value-based purchasing alone can penalize a hospital up to 2% of reimbursements and pay for performance can nullify a whole reimbursable patient case for certain departments (Barnes, et al., 2018). 

The current state of hospital staff health is congruent with an interceding state of mindlessness as described by Dr. Ellen Langer of Harvard University psychology department (2012). Without mindful training, the alternative is mindlessness which is the natural and common human mind state (Langer, 2012). Mindlessness is an inactive state of mind characterized by reliance on distinctions drawn from the past (Langer, 2012). In mindlessness, the past over-determines the present and one is trapped in a single perspective which is not context driven. Rules and routines govern one’s life. Mindless awareness people error frequently in recall but rarely doubt themselves (Langer, 2012). Mindfulness programs may contribute to improved hospital staff performance. 

Research Question 

How and to what extent do mindful awareness and mindful concentration programs improve hospital staff performance? 

Literature Review 

Literature Genres 

Research was gathered using Harvard’s Hollis database and Google Scholar database for peer reviewed journal articles and literature reviews. All efforts were made to use journal articles less than four years old. Some national government and committee websites were utilized for survey and statistical numbers. One Harvard University course (2017) and the research findings is also cited, along with two lectures by Harvard University professors. After a thorough review of the literature, hundreds of pro-mindfulness articles, two con-mindfulness articles and one healthcare application of a mindfulness program were found.  

To respond to the research question, this review is divided into topics. The first topic is hospital finances (the uninsured and underinsured revenue loss, reimbursement drops, job cynicism and high turnover, employee turnover costs). Following topics include mindful definitions, mindful programs and job performance/turnover, mindful programs and mental effects (positive effects, adverse effects), mindful programs and the brain (physical brain changes. brain networks, brain neuroimaging), mindful programs and physical health effects (immune system, interventions), mindful programs and education effects (hospital staff, hospital staff students). 

Hospital Finances 

Hospital finances and sustainability are a direct and inspiring source of hospital administrations’ motivation to implement mindfulness programs. Higher reimbursements motivate hospital administrations to pay for mindfulness staff programs. Mindfulness programs are currently considered a personal private choice not a workplace program. If the hospital administration does not have a financial reason to implement mindful programs, then mindful programs will not be implemented. So, an evaluation of hospital financial conditions is necessary. 

Hospitals are losing their ability to sustain themselves. The National Health Expenditure Report from the US government institution of Centers for Medicare and Medicaid Services states that America spent 3.3 trillion dollars on healthcare in 2016, $10,348 per person (2018). Healthcare absorbed 17.9% of the U. S. Gross National Product in 2016 (Centers for Medicare and Medicaid Services, 2018). Hospital expenditures account for 32% of the 17.9%, around one trillion dollars in 2016 (Garthwaite, Gross, & Notowidigdo, 2018). The insurance reimbursements which balance hospital expenditures are not optimal to run a thriving hospital due to non-insured patients, under-insured patients and decreasing hospital quality care penalties (Garthwaite, Gross, & Notowidigdo, 2018; Hsia et al., 2011). Hospitals lose money for at least three major reasons. The first reason is when people are uninsured or underinsured, the hospital absorbs the monetary loss.  

The uninsured and underinsured hospital revenue loss. 

First, reimbursements are decreasing due to uninsured hospital treatment costs and unpaid bill balances of the underinsured (Garthwaite et al., 2018; Hsia et al., 2011). For 2016, United States Census Bureau reports 28.1 million Americans are uninsured (8.8%) with 91.2% covered (2017). Even the 2010 Affordable Care Act (ACA), providing medical insurance to 20 million Americans, will only cover around 70% of personal medical costs (Garthwaite, 2018). The ACA excludes insurance membership for undocumented immigrants. Thirteen of the 20 million covered are enrolled in the Medicaid portion of the ACA. Medicaid recipients are children, disabled, pregnant, elderly or low-income meaning they will have difficulties paying their 30% portion (Garthwaite et al., 2018). 

According to the Commonwealth Fund Biennial Health Insurance Survey (CFBHIS) of 2017, there are 41 million underinsured Americans who may not be able to afford to pay their hospital bills (2017). Of these underinsured, 52% reported medical bill problems and 42% of the total uninsured amount reported going without needed care due to the cost (CFBHIS, 2017). Adding the uninsured and underinsured together means over 69 million people are most likely unable to pay their hospital bills, if they accrue them.  

It is tough to know how the government estimated 11.2 million undocumented illegal immigrants might add to these numbers since their numbers are not fully known (Castaneda, 2016). Lower costing doctors’ offices can and usually do turn uninsured illegal immigrants away or report their illegality to the authorities for deportation (Castaneda, 2016). Hospitals are mandated by federal law (if they receive federal funds, most do) to treat everyone until they are stabilized, regardless of insurance or immigration status (Castaneda, 2016). Illegal immigrants have a tendency to go to the hospital emergency departments with any sickness for these reasons, increasing the hospital’s uninsured treatment costs (Castaneda, 2016). 

The hospital absorbs the debt of unpaid services. Garthwaite, from the National Bureau of Economic Research, says hospitals are “the insurers of last resort” because they are essentially insuring the uninsured and underinsured by paying bill balances (2018, p. 1). Thus, hospital finances desperately need a profit infusion for sustainability. The second major hospital revenue loss, which is key to this paper’s research question, occurs when insurance reimbursements drop. 

Reimbursement drops. 

Second, reimbursements are dropping due to rising interests in quality patient care by the insurance companies. Insurance reimbursements are increasingly tied to healthcare quality (Barnes, Oner, Ray, & Zengul, 2018). The Agency for Healthcare Research & Quality’s definition of healthcare quality (2017): 

1. Safe: Avoiding harm to patients from the care that is intended to help them;  

1. Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively);  

1.  Patient-centered: Providing care that is respectful of and responsive to individual patient. preferences, needs, and values and ensuring that patient values guide all clinical decisions;  

1. Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care;  

1. Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy;  

1. Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. (p. 28) 

The only systematic review of the literature (self-proclaimed) comparing hospital quality performance and financial performance found a significant relationship between the two (Barnes, 2018). The study blames “the ever-increasing quality initiatives that are directly linked to the financial reimbursements” for decreasing hospital profits (Barnes, et al., 2018, p. 28). 

While there are multiple indicators used to gauge quality, a qualitative analysis type systematic review (n=10) concluded the most common factor for improving quality care was to specialize the staff in quality care (Mileski, Topinka, Lee, Brooks, McNeil, & Jackson, 2017). Not only do their quality care skills need to be in place but staff well-being needs to be cynicism free.  

Job cynicism and high turnover. 

Third, job cynicism results in high job turnover which is costly for hospitals (Huang Chuang & Lin, 2003; Kang, Twigg, & Hertzman, 2010). Cynicism also decreases hospital staff performance and may be resolved by mindfulness programs (Good, Lyddy, Glomb, Bono, Brown, Duffy, ... & Lazar, 2016). Decreasing costly cynicism and job turnover, motivates hospital administrations to implement workplace mindful programs which in turn, increases hospital staff performance.  

Cynicism and job turnover can have a considerable negative effect on a hospital both monetarily and by undermining the entire hospital culture (Mantler, Godin, Cameron, & Horsburgh, 2015). Employee cynicism is the belief that the leaders of the organization lack integrity (Stanley, Meyer, & Topolnytsky, 2005) and do not care about the employees (Wanous, Reichers, & Austin, 2000). It is expressed as distrust, pessimism, contempt and frustration toward the organization (Abraham, 2000).  

Employee cynicism increases due to excessive job demands, lack of work resources and leaders’ low level of trustworthiness (Kim, Bateman, Gilbreath, & Andersson, 2009). Cynicism negatively effects time, productivity, effort and performance (Kim, et al., 2009). It increases counterproductive work behaviors (Luksyte, Spitzmeuller, & Maynard, 2011). Cynicism causes employees to cut themselves off from organizational values and other employees which decreases teamwork and cooperation, compromising patient care (Mantler, Godin, Cameron, & Horsburgh, 2015). Once a high level of employee cynicism develops in an organization, it can stay high and because it is an attitude, it can also be lowered through organizational effort, according to Boersma and Lindblom (2009) along with Wanous, Reichers and Austin (2000). The actual hospital turnover costs add up to millions of dollars per year per hospital (University of New Mexico, 2016). 

Employee turnover costs. 

When hospital employees quit their jobs, it is very costly to hospitals. Keeping current workers employed is paramount for employers to save money. Mindfulness practices decrease job turnover (Dane, & Brummel, 2014), increasing hospital administrative motivation to implement workplace mindful programs. 

Due to the current lack of healthcare professional, replacing nurses and physicians will come at a high recruitment cost to hospitals (Mantler, Godin, Cameron, & Horsburgh, 2015). Even if hospitals could retain all of their current employees, they are predicted to become extremely short of employees due to growing elderly populations and increasing healthcare complexity (Canadian Nurses Association, 2009). Starting 2022, the Canadian Nurses Association (2009) predicts that, like most other countries, they will be short 60,000 nurses. In 2015, hospitals averaged an ongoing 7% nursing vacancy rate (University of New Mexico, 2016). Table 1 represents the findings of a medical center case study in 2001by Waldman, Kelly, Aurora, and Smith. 

Table 1 

Table 1 Annual Costs of Turnover in a Major Medical Center 

(Waldman, Kelly, Aurora, & Smith, 2004, p. 209) 

The researchers show turnover costs, for this facility, made up 5% of their annual operating budget in 2001 and the costs were most probably underestimated (Waldman, Kelly, Aurora, & Smith, 2004). It would be revenue neutral to offer each departing nurse 86% of his/her annual salary each year to stay or to give every nurse on staff a 33% bonus to stay another year (Waldman, Kelly, Aurora, & Smith, 2004).  

Even in 2001, the total turnover cost for this hospital in one year was $29.3 million and has continued to grow. According to the 2016 National Healthcare Retention and RN Staffing Report, the current cost of nurse turnover is between $37,700 - $58,400 per nurse (University of New Mexico, 2016) compared to approximately $37,000 in this 2001 chart. The turnover rate for nurses averaged 17.2% and nursing assistant turnover was 23.8% for the year of 2015 (University of New Mexico, 2016). Lowering job turnover costs helps to motivate hospital administrations to choose to implement workplace mindful programs. The role of mindfulness training for staff and management may play a multi-dimensional key role for increasing hospital quality care and financial performance to improve hospital sustainability. 

Mindful programs and job performance/turnover. 

General job-performance outcomes using mindful awareness and concentration interventions are abundant (Glomb, Duffy, Bono & Yang, 2011; Good, Lyddy, Glomb, Bono, Brown, Duffy, ... & Lazar, 2016). Two systematic reviews of the literature generalize the workplace outcomes into three categories: (a) improved physical and psychological well-being, (b) improved relationship quality and (c) improved performance (Glomb, Duffy, Bono & Yang, 2011; Good, Lyddy, Glomb, Bono, Brown, Duffy, ... & Lazar, 2016).  

An additional Singapore study found that if supervisors (n=96), from an industry range of education, service, financial, manufacturing) score high in mindfulness, then the supervisors have an increased ability to satisfy the needs of their staff (Reb, Narayanan, & Chaturvedi, 2012). Personal engagement, high energy levels, and productivity increase as a result of high mindfulness supervisors (Reb, Narayanan, & Chaturvedi, 2012). Staff work/life balance, overall job-performance and job-satisfaction also improve with a mindful supervisor (Reb, Narayanan, & Chaturvedi, 2012). A 10-day daily survey study using a control group (n=50) and self-taught (booklet) meditation awareness and concentration group (n=50). Participants were from hospitals, schools and medical practices in German cities found positive outcomes for increased job-satisfaction and less emotional exhaustion (Hülsheger, Alberts, Feinholdt, & Lang, 2013).  

In the high turnover restaurant industry, job-turnover intention (desire to quit scale) decreases when the leader is strong in mindful awareness and concentration according to a survey study (n=102) taken in seven restaurant chains throughout the American southwest (Dane, & Brummel, 2014). Since the number of participants in the workplace is high, this study may be applicable to hospital employees, as well. In a hospital setting, these monetary improvement results would increase hospital administration motivation to implement mindful staff programs. A plethora of research studies support increased work-engagement post mindful awareness and concentration interventions (e.g., Brown, Ryan, & Creswell, 2007; Dane, & Brummel, 2014; Hülsheger, Alberts, Feinholdt, & Lang, 2013; Leroy, Anseel, Dimitrova, & Sels, 2013). Definitions for mindfulness need to be made clear if used in the workplace. 

Mindful Definitions 

The popularity of mindful techniques has quickly escalated over the last two decades with the support of American physicians like Dr. John Kabat-Zinn. He has provided one of many definitions for mindfulness (2013, 1:02), “Mindfulness is the awareness that arises through paying attention, on purpose, in a very thoughtful way, in the present moment, non-judgmentally and as if your life depends on it.” Dr. Kabat-Zinn points out that focusing is the key and it does not matter what is focused on. Not to be confused with relaxing, mindfulness is the training of awareness monitoring (Kabat-Zinn, 2013). Mindful awareness and mindful concentration is also defined as the essence and experience of engagement, the noticing of new things and is what enlivens us (Langer, 2012). 

Types of mindfulness include concentration and awareness. Mindful concentration is the fixating on an object (transcendental meditation) like a mantra, breathing, a physical experience or a picture to disengage from thoughts or emotions (Hülsheger, Alberts, Feinholdt, & Lang, 2013). The purpose of mindfulness is to generate deep comfort and focus. Mindful awareness is fixating on the present moment, staying alert and being less judgmental during that moment. One strives to apply acceptance and compassion to observed thoughts and feelings. The aim of successful mindfulness is to break the chain of thought association and to stop reacting to those thoughts (Hülsheger, Alberts, Feinholdt, & Lang, 2013). Mindful concentration and mindful awareness are similar. The mindful practitioner probably alternates between the two no matter which one is intended. There is plenty of evidence for the mental effects of mindful programs. 

Mindful Programs and Mental Effects  

According to a lecture produced by the Harvard Medical School, there are four categories of mindful interventions (2008). Two of them fall into the sub-category of concentration type mindfulness: (a) concentrating with focused attention on an image, a sound (mantra) or a single-pointed object (body part, breath); (b) ethical enhancement like practicing loving kindness, compassion or forgiveness. The other two are in the sub-category of awareness type mindfulness: (c) receptive work or open monitoring awareness like diffusing attention toward any object that arises naturally or mental noting/labeling; and (d) awareness monitoring or mindful movements like yoga, tai chi and qi gong (Harvard Medical School, 2008). Let’s examine the positive and adverse effects of mindful interventions in the research. 

Positive effects. 

Mindful activities contribute to five areas of measurable improvement in the well-being of the mind, according to a Harvard Medical School lecture (2008, lecture): (a) intention (motivation makes a difference); (b) attention regulation (stability, control, and clarity); (c) emotion regulation (response inhibition and equanimity); (d) extinction and reconsolidation (of sensory-affective-motor scripts/schemas/biases); and (e) pro-sociality (empathy, ethical framework in social cognition). 

Mindfulness positively correlates to increases in happiness, relationship satisfaction, self-esteem, and competence memory (Jongman-Sereno, 2017). Attention, learning, creativity, charisma, leadership and productivity are also positively correlated to mindfulness (Langer, 2012). Positive correlations also exist between mindfulness and vision, hearing, weight loss, longevity and overall health and well-being among other attributes (Harvard Medical School, 2008). Mindfulness negatively correlates to prejudice, burnout, accidents, stress, alcoholism, attention deficit disorders, depression, anxiety, pain and insomnia (Harvard Medical School, 2008; Jongman-Sereno, 2017; Langer, 2012). Adverse effects to mindful practices also exist. 

Adverse effects. 

Adverse effects of mindful meditation practices have been reported in rare cases of long-term meditators during experience of extreme mental states (Shapiro, 1992). Transient negative effects have also been reported during meditation (Vanderkooi, 1997). Brown University approved Lindahl and colleagues’ study on adverse effects of mindful training, which used a self-report interview process (n=25) from 2010-2016 and a Buddhist meditation intervention (2017). To qualify, participants must have had adverse reactions to Buddhist derived meditation practices prior to 2010. Their past results ranged from minimal/transient to severe/lasting adverse reactions, such as depressive states or undesirable memories. The researchers talked on the phone to participants for approximately one hour with open-ended questions about their meditation practices. Their experiences ranged from very positive to very negative for each person. All responses to their experiences were considerably different. The study used seven domains of analysis: cognitive perceptual, affective, somatic, conative, sense of self, and social (Lindahl, Fisher, Cooper, Rosen, & Britton, 2017). Risk factors found in the study were lack of sleep, inadequate diet, and lack of exercise which led to increases in destabilizing or negative meditation experiences. Recreational drug use was another risk factor for negative experiences but cited by some as helpful in negotiating negative meditative events later. Some of the subjects were hospitalized during the time frame for psychotherapy or medical treatment (Lindahl, Fisher, Cooper, Rosen, & Britton, 2017). 

Practice approach or incorrectness of technique was also a risk factor for negative outcomes. Amount, intensity or inconsistency of practice was identified as a risk factor, too. All of their participants were mandated to practice one style for the study. The researchers found that the type of mindful practice can be a mismatch to the practitioner. Another risk factor is negative relationships throughout life, especially to teachers. Absent, unhelpful, not sympathetic meditation teachers and meditation community relationships predicted worse meditative difficulty vs. supportive, helpful and understanding teachers. This also held true for relationships outside their personal meditation groups (Lindahl, Fisher, Cooper, Rosen, & Britton, 2017) 

The most powerful argument against mindful interventions is about the quality of the mindful research being produced (Van Dam, van Vugt, Vago, Schmalzl, Saron, Olendzki, ... & Fox, 2018). In a critical study, Van Dam and colleagues (2018) found four major risk factors for mindful practices: “insufficient construct validity in research measures of mindfulness, challenges to (clinical) intervention research methodology, potential adverse effects from practicing mindfulness, questionable technological interpretations of data from contemplative neuroscience concerning the mental processes and brain mechanisms underlying mindfulness,” (p. 42). 

The Van Dam and colleagues research team argues that mindfulness measures are new and have not adequately been validated. Also, questionnaires, surveys and self-reports can easily be skewed by multiple factors which can make them potentially unreliable. According to Van Dam and colleagues, multiple, large, longitudinal randomized control trials which consider participant preferences of mindfulness practices to determine the full benefits and costs are missing from the literature (Van Dam, et al., 2018). The researchers are not fully convinced about the reliability and even warn against neuroimage findings concerning the brain (Van Dam, et al., 2018). With the previous warning in mind, next will be the examination of mindfulness programs and the brain literature. 

Mindful Programs and the Brain 

Problems with brain image findings in mindful research studies exists as well (Thompson, 2017; Van Dam, et al., 2018). Functional MRI’s have limitations and findings can be misinterpreted due to head turning and cardio/respiratory changes creating differences between individuals (Thompson, 2017; Van Dam, et al., 2018). Brain differences make findings hard to extrapolate to groups or the population and calculating valid estimates of effect size is extremely difficult in neuroimaging data (Thompson, 2017; Van Dam, et al., 2018). Additionally, researchers recognize that collecting data in a clinical environment may cause different results when compared to a natural environment. The study concludes by insisting on increased rigor in mindful definitions, data collection and methodology in mindfulness studies (Thompson, 2017; Van Dam, et al., 2018). One type of brain image cannot capture the process of mindfulness as it is not in a specific location nor is it a solitary event (Thompson, 2017). Researchers have documented size changes in areas of the brain, though. 

Physical brain changes. 

Having clarified the problems, there are some measurable physical brain changes that have been documented with mindful awareness and concentration practitioners. Typical brain shrinkage due to aging may be reduced in mindful practitioners (e.g., Harvard Medical School, 2008). In one study, 51-year-old mindful practitioners had equal brain gray-matter (neurons-communication) and white-matter (myelination-speed, accuracy) volume as 25-year olds, which indicated a much slower brain decline than normal brain aging (Harvard Medical School, 2008). Gray matter concentration changes in the Mindfulness-Based Stress Reduction program (MBSR) were magnetic resonance imaging measured for 16 healthy non-meditators before and after an 8-week MBSR program and compared with a 17-person waitlist group (Hölzel, Carmody, Vangel, Congleton, Yerramsetti, Gard, & Lazar, 2011). Increases in grey matter were confirmed for the intervention group in the left hippocampus, posterior cingulate cortex, temporo-parietal junction and the cerebellum suggesting gray matter concentration increases in brain areas involving learning, memory processes, emotion regulation, self-referential processing and perspective taking (Hölzel, et al., 2011). Additional measurable brain changes with mindful practices include, enlargement of the hippocampus (learning and memory), enlargement of the insula (convergent information processor), a shrinking amygdala (anxiety, fear, stress), improvements in the temporo-parietal junction (empathy) and improved changes in the brain stem mood molecules (Harvard Medical School, 2008). An abnormally functioning amygdala has been associated with anxiety, depression and post-traumatic stress disorder (Shin, & Liberzon, 2010). In addition to physical changes, brain networks research adds an additional level of brain evidence. 

Brain networks. 

The complex resting brain state of the brain is called the default mode network (DMN). The DMN controls self-referential introspective states (Mak, Minuzzi, MacQueen, Hall, Kennedy, & Milev, 2017), among other things. A meta-analysis study found the functional connectivity strength of a normal DMN follows an inverse U-shape (Mak, Minuzzi, MacQueen, Hall, Kennedy, & Milev, 2017). For example, DMN connectivity is strongest during adulthood and weakest during childhood and elderly years (Mak, et al., 2017). Cognitive functioning is positively correlated to DMN connectivity (Mak, et al., 2017). In a meditation study, researchers found that default mode network (DMN) brain areas are similar to meditation activity areas (Jang, Jung, Kang, Byun, Kwon, Choi, & Kwon, 2011). They compared 35 mediation practitioners with 33 non-meditators. Meditator had greater functional connectivity with the DMN in the medial prefrontal cortex area the non-meditators did. Their findings imply that long-term meditators may be associated with functional regional brain changes for areas related to internalized attention when not meditating as well (Jang, et al., 2011). During a study using Mindful-Based Exposure Therapy (n=31) using an fMRI for analysis found increased whole brain connectivity between the default mode network, functional connectivity and the dorsal attention network during the mindfulness task (King, Angstadt, Sripada, & Liberzon, 2017). Their findings support mindfulness training is associated with improvements in rumination, post-traumatic stress disorder and depression. Default mode network (DMN) increases connectivity to attention networks during mediation tasks (King, Angstadt, Sripada, & Liberzon, 2017). Neuroimaging can show where mindfulness activities land within the brain networks. 

Brain neuroimaging. 

In a meta-analysis using 22 neuroimaging studies comparing novice (n=11) vs. experienced meditators (n=12), researchers documented a difference (Falcone, & Jerram, 2018). For novices, the focus of brain activity appears to be in the insula. Experienced meditators show their foci of brain activity in the frontal gyrus and the globus pallidus (Falcone, & Jerram, 2018). A systematic review of seven functional magnetic resonance imaging (fMRI) studies also found a focus of activity in the insula but they could not find robust evidence for the prefrontal cortex sub-regions (Young, van der Velden, Craske, Pallesen, Fjorback, Roepstorff, & Parsons, 2017). Another fMRI meta-analysis using 78 studies and a total of 527 meditation participants found medium effect sizes for activation and deactivation consistently in the insula, pre-supplementary motor cortices, dorsal anterior cingulate cortex and the fronto-polar cortex during seven different types of meditation practices: visualization, sense-withdrawal, non-dual awareness practices, focused attention, mantra recitation, open monitoring and compassion/loving-kindness (Fox, Dixon, Nijeboer, Girn, Floman, Lifshitz, ... & Christoff, 2016). Another meta-analysis using 21 neuroimaging studies totaling 300 meditation practitioners found a global medium effect size for eight consistent brain areas altered and increased in meditators: the frontopolar cortex/BA 10 (key to meta-awareness), sensory cortices and insula (exteroceptive and interoceptive body awareness), hippocampus (memory consolidation and reconsolidation), anterior and mid cingulate/orbitofrontal cortex (self and emotion regulation) and superior longitudinal fasciculus; corpus callosum (intra and inter hemispheric communication), (Fox, Nijeboer, Dixon, Floman, Ellamil, Rumak, . . . & Christoff, 2014). Several important studies have established beneficial outcomes like achievement of different fine motor skills, playing a musical instrument, enhanced ability for physical activities follow brain structural increases in gray and white matter (Fox, et al.,  2014). 

A specific fMRI study of mindful meditation-chanting compared the “OM” chant to and “SSSS” chant in 12 healthy men, with 10 rounds of 15 second on/off chanting and found a significant deactivation of the anterior cingulate, para-hippocampal gyri, thalami, hippocampi, bilateral orbitofrontal and the right amygdala in comparison to the brain resting state, only during the “OM” chant. (Kalyani, Bangalore, Venkatasubramanian, Ganesan, Arasappa, Rashmi, … & Gangadhar, 2011). An important question is: Do the brain findings translate into physical health benefits? 

Table 2 

Meditation  Activity location	Population	Type of Meditation
Insula	Novices (Falcone, & Jerram, 2018); Mean age = 30, possibly novice participants due to age (Young, et al., 2017); experienced meditators (Fox, et al., 2016); Global medium effect size, 20-65 years old, structural increase changes (Fox, et al., 2014)	Various mindful meditations (Falcone, & Jerram, 2018); MBCT mindfulness based cognitive therapy, MBSR mindfulness based stress reduction (Young, et al., 2017);  See below for  (Fox, et al., 2016) and (Fox, et al., 2014)
Frontal gyrus & globus pallidus	Experienced meditators (Falcone, & Jerram, 2018);	Various mindful meditations (Falcone, & Jerram, 2018)
Pre-supplementary motor cortices, dorsal anterior cingulate cortex and the fronto-polar cortex	Global medium effect size, experienced meditators (Fox, et al., 2016); Global medium effect size, age 20-65, structural increase changes (Fox, et al., 2014)	Focused attention meditation, mantra meditation, open monitoring attention meditation, loving kindness meditation (Fox, et al., 2016); See below for (Fox, et al., 2014)
Sensory cortices, hippocampus, and superior longitudinal fasciculus; corpus callosum	Global medium effect size, age 20-65 structural increase changes (Fox, et al., 2014)	Insight, Zen, Tibetan Buddhist, MBSR; mindfulness-based stress reduction, IBMT; integrative body-mind training, BWV; brain wave vibration, Soham, LKM; loving kindness meditation, various meditations (Fox, et al., 2014)
Deactivation of the anterior cingulate, para-hippocampal gyri, thalami, hippocampi, bilateral orbitofrontal and the right amygdala in comparison to the brain resting state	Age 22-39, n=12, 4 = experienced, 8 = novices (Kalyani, et al., 2011)	OM chant

Table 2: Chart of neuroimaging research presented  

Mindful Programs and Physical Health Effects 

According to a lecture by Harvard Medical School, cell production improves and positive gene expression changes occur for health protective factors of mindful practices (2008). Enhanced gene energy metabolism and mitochondria function, insulin secretion and telomere maintenance (age control) are all improved with mindful awareness practice (Harvard Medical School, 2008). Eight weeks of a 20-minute mindful practice led to inflammation reduction genes turning on, plus immune system changes (Harvard Medical School, 2008). The Immune system plays a central role in physical health. 

Immune system. 

The immune system protects the body from disease and detrimental foreign bodies (Zimmerman, 2016). The immune system is capable of identifying and resolving attacks by viruses, bacteria, parasites, cancers and additional threats (Zimmerman, 2016). The immune system fluctuates in strength and capabilities according to the autonomic nervous system (Diego, Field, Sanders, & Hernandez-Reif, 2004). Together the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS) make up the autonomic nervous system, which is responsible for unconscious bodily functions like breathing, heart rate and digestion. The 10th cranial nerve (the vagus nerve) registers low tone when the “fight or flight” SNS operates and high tone when the PNS operates (Diego, Field, Sanders, & Hernandez-Reif, 2004). 

A multitude of studies connect high vagal nerve tone, which is an indicator of active PNS, to protective factors of the immune system for improved health (e.g., Kok, Coffey, Cohn, Catalino, Vacharkulksemsuk, Algoe, ... & Fredrickson, 2013). For example, human natural killer cells “eat” cancer, bacteria and virus cells. Cortisol, a hormone increased by the SNS, “eats” natural killer cells belonging to the immune system. Thus, low tone vagal activity lowers the amount of natural killer cells fighting for the immune system (Diego, Field, Sanders, & Hernandez-Reif, M.,2004; Brittenden, Heys, Ross, & Eremin, 1996). Low vagal tone also forecasts high inflammation (Thayer & Sternberg, 2006), myocardial infarction risk and lower survival odds after heart failure among other poor health outcomes (Bibevski & Dunlap, 2011). 

A research study (Kok, Coffey, Cohn, Catalino, Vacharkulksemsuk, Algoe, ... & Fredrickson, 2013), took advantage of known vagal tone outputs for its quantifiable measurements. High-frequency components (0.12-0.4 Hz) of the heart rate signal reflect vagal influences on the heart. Once considered stable and unchanging, vagal nerve baseline can indeed be changed: It has plastic properties (Kok, et al., 2013). Researchers used 71 university faculty/staff and one intervention to test the baseline of the vagus nerve. For six weeks, subjects performed a mandatory one-hour per week loving-kindness meditation. Plus, they self-decided frequency and duration of daily meditations. Baseline vagal nerve tone was taken two weeks before the intervention and one week after. The baseline vagal tone was higher post intervention with variations. For participants who started with a higher baseline vagal tone, their positive emotions had a steeper increase during the study. The amount of increase in vagal tone post intervention positively correlated to the increased amount of self-reported positive emotion and positive social connections experienced by the end of the study (Kok, et al., 2013). Certain types of intervention meet the requirements of increasing vagal tone. Research exists for these interventions. 

 Interventions. 

Exercise interventions like aerobics and weight lifting require activation of the SNS to increase heart rate. So, low vagal tone, which indicates activation of the SNS, is associated with exercise and stress (Lucas, Heidi, Porges, & Rejeski, 2016). Also, additional to meditation, three other interventions show great promise: yoga, tai chi and massage therapy (Riley & Park, 2015). Even in rigorous yoga and tai chi exercises the nervous system alternates from SNS to PNS activation promoting efficient shifting from arousal to calm (Lucas, et al., 2016) leaving the practitioner with a higher vagal tone baseline post intervention (Sullivan, Erb, Schmalzl, Moonaz, Noggle, Taylor, Porges, & Porges, 2018). Autonomic neural regulation, the ability to change from SNS to PNS activation reciprocally, is linked to improved breast and prostate cancer outcomes (Couck, Marechal, Moorthamers, Laethem, & Gidron, 2016; Magnon, Hall, Lin, et al., 2013).  

In a systematic review of 71 journal articles (Riley & Park, 2015), yoga improved positive affect, mindfulness and self-compassion with inhibition in the posterior hypothalamus, decreasing interleukin-6 (inflammation indicator), decreasing C-reactive protein and decreasing cortisol levels. Yoga also raises vagal tone (Sullivan, Erb, Schmalzl, Moonaz, Noggle, … & Taylor 2018) as does massage therapy (Hernandez-Reif, Field, Ironson, Beutler, Vera, Hurley, ... & Hernandez-Reif, M., 2005; Hernandez-Reif, Ironson, Field, Hurley, Katz, Diego, ... & Burman, I., 2004). Research on tai chi shows high tone vagal activity, as well (Wei, Li, Yue, Ma, Chang, Yi, … & Zuo, 2016).  

 Each intervention requires different senses which means different brain processing pathways are activated and strengthened to achieve high vagal tone (Kayser & Shams, 2015). For example, yoga and tai chi require muscle movement, balance and eyesight brain processes. Sitting meditations and massage do not. Breath regulation, which directly affects the vagus nerve (Song, Liu, Proctor, & Yu, 2015), is required by all four interventions but at different tempos and efforts requiring different neuro-pathways (Kayser & Shams, 2015). Yoga and massage researchers hypothesize the increase in vagal tone comes from pressure on the skin receptors (also part of the vagus nerve system) unlike tai chi and meditation (Hernandez-Reif, 2004; Hernandez-Reif, 2005). Combining the four interventions of yoga, meditation, massage therapy and tai chi may have cumulative health benefits due to their differences, though little research on this topic has been done. Because these interventions are not widespread in hospitals, a need to examine mindful education research is necessary. 

Mindful Programs and Education Effects  

Research claims mindfulness programs are more successful in the presence of local champions, leadership buy-in, prior mindfulness exposure of participants and if the program was voluntary vs. mandatory (Byron, Aiedonis, McGrath, Frazier, deTorrijos, & Fulwiler, 2015). In contrast, downfalls to successful programs are insufficient training coverage, insufficient time given to planning and effective program communication, not enough time for staff attendance to training sessions and logistics (Byron, et al., 2015). As of 2018, applied mindful intervention education research for healthcare workers is rare but one hospital staff study exists (Duggan, & Julliard, 2018).  

Hospital staff. 

In 2018, researchers Duggan and Julliard conducted a multi-level, hospital staff, mindful education research study with social workers and therapists (n=4), nurses (n=7), doctors (n=2) and administrative staff and leaders (n=7) as leadership facilitators. The healthcare facilities used were one inner-city teaching hospital, a number of schools, public clinics, a homeless-persons’ clinic and diverse social support centers. All 20 volunteered to educate their respective departments (Duggan, & Julliard, 2018). Due to hospital time constraints the obvious choice for a starting point was a brief intervention (Duggan, & Julliard, 2018). Mindful Minute Intervention (MMI), a brief one to three-minute staff intervention based on the Joy of Living program of the Tergarr Meditation Community, was used. Focused attention, open presence and a relaxed recognition of awareness was central to the practice incorporating awareness and concentration (Duggan, & Julliard, 2018).  

The volunteer facilitators were asked to begin meetings, shifts, patient room-entry and/or classes with MMI and were interviewed post experiment, six weeks later. Facilitators were taught the guidelines of how to introduce the MMI to a group, when it should be used and how to lead the MMI. Training included an in-person one-hour group training with role-play/feedback and a 10-minute online training video. A printed guide and script were provided for both the one minute and three-minute options. Predicted obstacles for facilitators were coercion refusal, ‘is it my place’ type questioning, burden of leadership and competing priorities (Duggan, & Julliard, 2018).  

Six weeks later, facilitators reported staff benefits which included personal stress relief, positive energy shift, increased level/tenor of group participation, improved sense of human connection, caring and shared reality, positive-tone foundation for the segment of time (i.e. meeting), increased personal focus for reduction of errors, better productivity/efficiency, increased presence with a quality of non-resistance to current circumstances, desire for more healthy self-care, immediate emotional presence benefit and relaxation of the practitioner contributing to relaxation of the patient (Duggan, & Julliard, 2018). The researchers predicted all the outcomes from their preliminary research but in a different frequency amount order than expected. The only two outcomes they did not predict at all were energy shift and improved sense of human connection. Surprisingly to Duggan and Julliard (2018), both energy shift and improved sense of human connection scored in the top four for most frequently occurring. The researchers were also surprised by the high number of interpersonal attributes (three of the top five) compared to intrapersonal attributes (Duggan, & Julliard, 2018). In contrast to this one study for hospital staff, many studies have been conducted with healthcare students which could be generalizable. 

Hospital staff students. 

Finally, a meta-analysis of 19 studies of students (grand total of participants, n =1,815) in the fields of medicine (n=10), nursing (n=4), psychiatry (n=1), social work (n=1) and other healthcare realms (n=3) analyzed the effects of mindfulness training for healthcare students’ mood, stress, depression, self-efficacy, empathy and anxiety (McConville, McAleer, & Hahne, 2017). Results showed decreases in stress, anxiety and depression along with improvements for mindfulness, mood, self-efficacy and empathy post mindful interventions. This meta-analysis recommended mindful training be implemented into the training of healthcare professionals due to its easy implementation and positive results (McConville, McAleer, & Hahne, 2017). 

Most of the articles mentioned easy implementations and low costs of the mindfulness interventions. None of the articles mentioned any adverse effects during their research. A few mentioned that there could be adverse effects with reference to the Van Dam and colleagues (2018) article and the Lindahl and colleagues (2017) article but none were found with their study participants. The search for these articles began with the intent of research for hospital staff. 

Methodology 

After researching the combined search words working mindful programs for hospital staff, it became apparent that few studies have been produced on this topic. Looking at the literature, no studies were found (but may exist) which tied hospital administration costs and employee well-being advantages to working mindfulness programs, so that became the focus of the research question. The most probable cause for this lack is hospital mindfulness program funding. Thrifty business administrations need a monetarily motivational reason to invest in mindfulness programs. First, the hospital financial situation research needed to be explored. Once the key element of quality of care reimbursements was found, its research needed to be uncovered. While researching hospital financial situations, decreasing job turnover costs also was discovered to be great motivator to employers and also improved by mindfulness according to the mindfulness literature. Job turnover research lead to the reasons for it, like cynicism and employee well-being. This review’s methodology was to piece together the literature from the scientific fields of mind, body and brain research to understand if there were enough evidence and motivational elements for hospitals to implement mindful programs to improve staff well-being and thus staff performance. Once promising research was uncovered for those three topics, deep analysis of mindfulness education topics was explored. 

Analysis 

How can hospital staff produce patient health when they don’t have mental or physical health themselves? America’s hospital staff have an abundance of health knowledge (ensured by the medical licensure process) with low level quality patient care application skills (Garthwaite, Gross, & Notowidigdo, 2018). The lack of health application skills is evident by the current poor state of hospital quality of patient care scores. (Garthwaite, Gross, & Notowidigdo, 2018).  

The hospital system’s weak link is the condition of the staffs mental and physical well-being which is decreasing the staff’s performance level. The answer to this papers research question (How and to what extent do mindful awareness and mindful concentration programs improve hospital staff performance?) is an extremely important one. Two large systematic reviews (Glomb, et al., 2011; Good, et al., 2016), plus six additional studies listed in this paper’s literature review, establish worker performance improves with mindful programs as well as improved physical/psychological well-being and relationship quality. Not only is hospital staff performance important to patient quality care and hospital sustainability but job performance positively correlates to a staff member’s quality of life (Glomb, et al., 2011; Good, et al., 2016).  

Mindfulness hospital models built on unified evidence from the fields of mind, body, brain and education are rare due to the need to analytically overlap different scientific fields. Currently in hospitals, mindful practices are considered a personal choice activity, like running or camping (Duggan, & Julliard, 2018). Healthy extra-curricular activities are encouraged by hospital administrations to their staff but are rarely wired into the daily workplace system to ensure execution (Duggan, & Julliard, 2018). Hospital administrations may not have examined how consistently positive the meta-analyses’ evidence is throughout the scientific fields.  

All four fields of mind, body, brain and education are heavily and consistently presenting the same positive outcomes from mindfulness programs. Mental improvements are heavily documented in a 19 study meta-analysis (n= 1,1815) for mindfulness program and recommends implementation (McConville, et al., 2017). Physical improvements are also heavily documented in meta-analyses for mindfulness program benefits (Bibevski & Dunlap, 2011; Brittenden, et al., 1996; Diego, et al., 2004). Neuroimaging meta-analyses backup the other fields with evidence of physiological brain improvements with mindfulness; one using 78 studies and 527 participants (Fox, et al., 2016) and another using 21 studies and 300 participants (Fox, et al., 2014).  

Only two studies, one referencing the other (n=25), were found for this review to expose risk factors of negative emotions post mindfulness meditation (Lindahl, et al., 2017; Van Dam, et al., 2018). When viewed through these multiple lenses, the solution to the problem of poor hospital staff health, poor quality patient care and poor hospital finances comes into clear focus. Evidence in the mental, physical and brain imaging studies is consistently in unified supportive of mindfulness program implementation. 

 The fourth construct is education and this too must be built on evidence. While the hospital problems of staff performance seem dire, the problems can improve with education (Boersma, & Lindblom, 2009; Wanous, et al., 2000). The strength and multi-faceted positive well-being improvements from mindfulness programs can no longer be ignored when viewed from this global multi-lens perspective. The increased employee performance evidence for mindful programs is well established in the literature but the working hospital applications are not (Duggan, & Julliard, 2018). 

Education Programing 

The one example found in this literature review was that of Duggan and Julliard (2018). Their program was only a preliminary six-week trial application. A more comprehensive plan would be needed to achieve the long term goals for hospital cultural change and ongoing improved staff performance. This analysis will attempt to bring together the current educational literature supporting a comprehensive mindful hospital staff program to increase staff performance. 

Hospital and Staff Buy-in 

Leadership buy-in is a program risk factor for program failure (Byron, et al., 2015). Two of the previous strong and current systematic reviews conducted by Barnes and colleagues (2018) and Mileski and colleagues (2017), link decreasing hospital profits with poor quality care and improving hospital patient care with staff training as the evidence-based, best-practice option. These studies show that it is in every hospitals financial best interest to invest in the mental health of their staff.  

Also important to hospitals is the accessibility of a comprehensive, evidence-based, time-efficient, cost-effective mindful program that their staff will accept. According to Byron and colleagues (2015), successful buy-in for staff  requires slow implementation with volunteers which helps accommodate fear of the unknown or fear of change. Best-practice would be to introduce the mindfulness cultural change in phases with the six-week MMI (e.g., Byron, et al., 2015; Duggan, & Julliard, 2018) as Phase I. 

Phase I 

A replication of the Duggan and Julliard (2018) study and the MMI would be optimal due its successful improved staff performance outcomes and staff buy-in power. Six facilitators had at least one staff member who was resistant to the program (Duggan, & Julliard, 2018). Four of the six facilitators witnessed positive-attitude changes over time toward the program without any leader coercion. Two facilitators did not. This was a very important finding to ensure the success of the program. Also, the importance of the excitement level generated by Phase I for leaders to implement broader programs after a six-week volunteer program is significant enough to justify staff and administrative buy-in motivation for Phase II. 

Phase II 

The best foundation for the second phase should be based on the guidelines of the people who experienced Phase I. Afterward, the hospital staff leaders of the Duggan and Julliard (2018) study requested institutional support, more education, more leaders and total hospital involvement to move forward into the next level (2018). In addition to their suggestions, risk factors can be addressed during this phase. 

To support moving to Phase III and to satisfy Van Dam and colleagues’ (2018) risk factors of “insufficient construct validity in research measures of mindfulness and challenges to clinical intervention research methodology,” valid and reliable tests need to be implemented in Phase II (2018, p.42). Phase III would require a larger financial hospital investment. Positive outcome measurement results would be needed to motivate hospital administrator to invest in wiring the program into the hospital culture. Positive outcome results would motivate the hospital staff to continue to participate in Phase III of the program, as well.  

Phase III 

Phase III development evidence is based on resolving risk factors presented by the evidence: adverse emotional reactions (Lindahl, et al., 2017), logistics (Duggan, & Julliard, 2018) and hospital support (Byron, et. al., 2015; Duggan, & Julliard, 2018). As discussed in the problem section of this paper, healthcare professionals experience trauma regularly and may not be as mentally healthy (King, et al., 2017; Speroni, et al., 2014) as naive healthcare students studied in McConville colleagues (2017) meta-analysis.   

The Lindahl and colleague’s (2017) study on adverse emotional effects of mindfulness meditation may have participants that are more similar to hospital staffs’ mental state. In the Lindahl and colleagues (2017) study, the participants were 25-60 years of age, which is a similar age to hospital staff, and they have had trauma in their past. Although, in the Lindahl and colleagues (2017) study low participant number (n=25)  and the self-report interview process used make it weak, it’s findings should still be considered when developing a comprehensive successful mindful program because the participants are somewhat of a psychological match to that of hospital staff.  

Similar to hospital staff, the participants Lindahl and colleagues (2017) study were unhealthy people before the mindfulness program, evident by the risk factors they listed. While in the study, the participants said adverse emotional effects increased with lack of sleep, inadequate diet, lack of exercise, drug use, unsupportive teachers and unsupportive social networks (Lindahl, et al., 2017). The suggestions of these authors need to be implemented into any mindful program for hospital staff to avoid detrimental program outcomes. Warning posters of possible emotional problems and access to on call hospital psychologists would help resolve this problem. According to Lindahl and colleagues (2017), offering more than one type of mindfulness intervention may reduce emotional risk factors, too. This validates adding interventions like yoga and tai chi in Phase III to the meditation interventions presented in the MMI of Phase I. 

Logistics was a program risk factor reported by the participants of the Duggan and Julliard (2017) experimental study. Small and private mindfulness rooms for hospital staff intervention use would be suggested for a logistics solution.  To increase hospital administration motivation to invest in a space for private practice on hospital property, cost-effectiveness must be thought through to ensure success. Small rooms with badge entry, security cameras and intervention videos would eliminate the cost of mindful teachers and reduce overall costs. 

The low financial commitment of adding technology based mindful rooms could motivate hospital financial support but the hospital would also need to supply support in the form of mindfulness education (e.g., Duggan, & Julliard, 2018). Education videos for new hires and annual continuing education given by the existing human resources department. No new hospital departments would be needed, helping to decrease costs of a mindful program implementation and increasing hospital administration buy-in. By addressing risk factors for Phase III, a cost-effective best-practice mindfulness program can be developed to indefinitely improve staff well-being and performance, thus changing the hospital culture to one of mindfulness as opposed to mindlessness.  

Weaknesses 

The weakness of this paper is the lack of evidence found for mindfulness education. A thorough investigation was made but little was found. There could possibly be more evidence. Also, some data was old. Table 1 used for job turnover statistics was from 2001.  A current table was not uncovered in the literature search for journal articles but it may be available in an internet census type website. Additional future research needed will be discussed in the following conclusion. 

Conclusion 

Limitations of the Study and Recommendations for Future Studies 

Research for Phase I exists but Phase II and Phase III need to be applied and then researched thoroughly for future comprehensive hospital mindfulness programs to become standardized. Research evidence is also missing for the cumulative effects of multiple mindful interventions used together, which is suggested in Phase III. If hospital workplace programs described here are encouraged, the research community would need to be alerted to the research opportunities and be consulted about best-practice outcome measurement tools and methodology. 

New research studies would have the potential to improve the mindful programs, springboard programs to other hospitals and help standardize programs for best-practice. With increased positive research, other fields would have the motivation to begin mindful workplace programs. Programs could begin due to the findings in this paper. 

Answers to the Research Question 

These literature review findings clearly answer the research question: How and to what extent do mindful awareness and mindful concentration programs improve hospital staff performance? Mindfulness programs improve hospital staff performance by improving staff well-being, improving patient quality care, decreasing staff mindlessness and decreasing staff cynicism. In turn, these results fiscally improve hospitals by increasing hospital insurance reimbursements and decreasing job turnover costs. These two financial factors plus the humanistic desire to improve the health of their staff provide hospital motivation to spend money and dedicate time to develop a mindfulness workplace culture. Changing hospital cultures to reflect health instead of post-traumatic stress disorder type anxieties and ensuring hospital financial sustainability for the future is the expanded extent of implementing mindfulness programs for improved staff performance. 

General Summary 

In America, the pattern of supporting people in troubled situations exists. Programs are developed to put out fires where there are problems, which is a natural reaction to a problem. Services are provided for at risk children. Anger management programs are provided for prisoners. Patient advocates are assigned to hospital patients with hospital care problems.  

Globally, this paper is proposing that tailor-made mindful programs be provided to the staffs within all caregiving systems: the people in the infrastructures. When the infrastructure groups get mentally and physically healthy, then the people they service can be reached and supported. The solution lies with mindful support programs for the parents, the prison guards and the healthcare providers, for example. It is the caregivers of the world that need tailor-made mindful awareness and mindful concentration education program implementation, first. Because everyone in America eventually goes through the healthcare system (as opposed to the prison system), the healthcare system is the most logical place to begin. 

Healthcare workers are also community health consultants, shoppers, car drivers, volunteers, husbands, wives, daughters, sons, friends and even parents. They participate in multiple aspects of their communities and there are over 12.5 million healthcare workers in the United States (Henry J. Kaiser Family Foundation, 2015). They live in almost every town in America. If mindful programs improve healthcare workers’ mental and physical health, it would affect everyone around them, not just themselves and their patients (Glomb, et al., 2011; Good, et al., 2016). The profound and significant positive mind, brain, health and education results found in this review of the literature have the potential to carry over into their private lives, improving not only the hospital culture but the American culture. To take this one step further, American culture influences world cultures.  

Phase I- Mindful Minute Intervention for Volunteer Groups 

The program would need three stages because leadership buy-in is a program risk factor for program failure (Byron, et al., 2015). Slow implementation in phases helps accommodate fear of the unknown or fear of change, improving chances of program success (Byron, et al., 2015). 

Since it was successful, the Duggan and Julliard mindful hospital staff program study example would become the first phase of the three-phase program (2018). Phase I will be six-weeks long because, in the study, that was sufficient time to achieve participant program buy-in and enough positive results to progress to the next phase. Two-thirds of resistant staff members changed their negative program attitudes without leader coercion after six-weeks. At the end of the study, all of the leaders were eager to expand their mindful groups and their staff members were reporting positive results including gratefulness for the mindfulness program (Duggan & Julliard, 2018).  

The program will begin with only 20 volunteer staff leaders within the hospital, as the successful study did (Duggan & Julliard, 2018). By using a smaller sample size and making it volunteer-based, the researchers increased hospital-wide staff curiosity and personal choice. Thus, they increased the programs chances of survival (Byron, et al., 2015; Duggan, & Julliard, 2018). These strategies are critical to the first phase’s success. 

The Mindful Minute Intervention, alone, was successful and needs to be used for Phase I (Duggan, & Julliard, 2018). Results from the Mindful Minute Intervention consisted of personal stress relief, positive energy shift, increased level/tenor of group participation, improved sense of human connection, caring and shared reality, positive-tone foundation for the segment of time (i.e. meeting), increased personal focus for reduction of errors, better productivity/efficiency, increased presence with a quality of non-resistance to current circumstances, desire for more healthy self-care, immediate emotional presence benefit and relation of the practitioner contributing to relaxation of the patient (Duggan & Julliard, 2018). These six-week results are amazingly constructive for the goal of increasing staff productivity but according to the leaders (participants) in the study more is possible to achieve (Duggan & Julliard, 2018). Phase II will be based on their recommendations and the literature.  

Phase II-Globalizing the Mindful Minute Intervention 

Since no additional hospital staff studies were found in the literature, the best foundation for the second phase will be based on the guidelines of the people who experienced Phase I: the hospital staff leaders of the Duggan and Julliard study (2018). In addition to their suggestions, two of the risk factors proposed by Van Dam and colleagues (2018) can be resolved during this phase. 

At the conclusion of the Duggan and Julliard study (2018), the staff leaders wanted institutional support, more education, more leaders and total hospital involvement to move forward into the next level. In Phase II, the Mindful Minute Intervention will be offered to all departments hospital-wide. The human resources department will be responsible for administering the one-hour training meeting detailed in the Duggan and Julliard study (2018). The Phase II process will begin by having one volunteer Mindful Minute Intervention squadron in each hospital department for six-weeks because six-weeks has been proven to produce positive outcomes (Duggan, & Julliard, 2018). Then, other volunteer squadrons in that department can be added every six weeks. If other hospital workers want to join, they must wait six-weeks for the next training. That helps the human resources department not become overwhelmed but it also creates demand for the product. This continues until whole departments are trained. Since the program will be implemented by the human resources department, it will also be part of the supervisor new-hire training process.  

For additional education, all employees will watch an annual mindful education video or power-point presentation along with their other human resource annual requirements, like safety videos. A longer, more in depth mindful education video/ power-point will be required of all hospital new-hires to help with program buy-in.  

To support moving to Phase III and to satisfy Van Dam and colleagues’ risk factors of “insufficient construct validity in research measures of mindfulness and challenges to clinical intervention research methodology,” valid and reliable tests must be implemented in Phase II (2018, p.42). Phase I was more focused on setting up the hospital staff buy-in but Phase II justifies outcome measurements. Phase III is going to require a larger financial hospital investment and for that, positive outcome measurements will be needed.  

Before and after Phase II, every participant will take a computerized quality of life (QOL) test given by the human resources department. This paper recommends the SF36v2 Health Survey for the staff population. Many QOL tests are disease specific but this one has been proven to be generically valid and reliable for all ages (18 years or older), for all diseases and for all treatment groups (Optum, 2018). The participants will also take a Turnover Intention Test (Kelloway, Gottlieb, & Barham, 1999) which has adequate internal reliability consistency (α = .88). Also having internal reliability consistency (vigor: α = .70; dedication: α = .83; absorption: α = .80), the Work Engagement Scale will be taken (Schaufeli, Salanova, Gonzalez-Roma, & Bakker, 2002). Both the Turnover Intention Test and the Work Engagement Scale will be taken anonymously to increase honesty in reporting. The tests will be grouped by department to help with departmental research analysis. To further increase honesty in reporting, the participants will be primed before taking the tests that the anonymous tests will only be used for program research and cannot be used against their job security. The Turnover Intention Test and the Work Engagement scale were used with positive results to show improved staff performance in the Dane and Brummel study (2013). 

Using these types of tests are a way of bypassing the mindful outcome measurement tools like the Mindful Attention Awareness Scale which has been criticized as showing little differentiation across respondents (Van Dam, et al., 2018). Mindfulness outcome tests are only two decades old and have not attained the validity and reliability standards required for strong outcome reporting, yet. A mindful program would not be limited to these three tests. These tests are chosen because of their validity, reliability and capability of providing staff performance feedback. 

Optimistically, one can presume the Phase II outcome measurement tests will deliver similar positive outcomes for staff performance, as the literature review studies did. This will validate hospital Phase III expenditure. Phase III involves the development of a mindful hospital staff culture. 

Phase III- Mindful Hospital Culture 

The Mindful Minute will continue to be used but the implementation of more powerful mindful interventions will become infused into the workplace to support a mindful hospital staff culture. 

Interventions for Phase III. 

 This paper’s literature review has found high positive outcomes using yoga, tai chi, massage and meditation interventions for optimal mental and physical health (Bibevski & Dunlap, 2011; Brittenden, et al., 1996; Couck, et al., 2016; Diego, et al., 2004; Harvard Medical School, 2008; Hernandez-Reif, et al., 2004; Hernandez-Reif, et al., 2005; Kayser & Shams, et al., 2015; Kok, et al., 2013; Lucas, et al., 2016; Magnon, et al., 2013; Sullivan, et al., 2018; Wei, et al., 2016). Because these interventions do not need special clothing, no special floors, very little space, no equipment, no post-shower needed, nor any shoes, they are chosen. They are also the most cost effective and work friendly intervention choices.  

Mental and physical health spiral up together or they spiral down together. Positive strength in both are necessary for each to proliferate and thrive (source?). For a mindful education program to be maximally successful both mental and physical mindful interventions must be included (Kayser & Shams, 2015). There is a plethora of research here supporting the mental and physical improvements of mindful interventions, including a strong and current systematic review of 71 journal articles (Riley & Park, 2015). Due to their different neuro-plasticity and brain area benefits, combining the interventions of yoga, meditation, massage therapy and tai chi may have cumulative mental and health benefits.  

Improved physical well-being, improved psychological well-being and improved relationship quality with mindful programs increase job performance, according to two systematic reviews; Good and colleagues (2016) and Glob and colleagues (2011). Additional evidence-based research supports the claim that mindful programs improve job performance and decrease job turnover (Brown, et al., 2007; Dane, & Brummel, 2014; Leroy, et al. 2013). Staff work/life balance, overall job-performance and job-satisfaction, personal engagement, high energy levels, co-worker support and productivity increase as a result of mindful programs, too (Hülsheger, et al., 2013; Reb, et al., 2012). These positive mindful intervention outcomes produce more support for improved hospital staff performance by utilizing mindful interventions. WHY? 

Certain interventions are not going to be chosen based on the finding in this literature review. According to Lucas and colleagues (2016), aerobics and weight lifting increases the sympathetic nervous system (SNS) which is associated with stress and exercise in general. Quantitative research on high vagal nerve tone post mindful programs of meditation, yoga, tai chi and massage show parasympathetic nervous system activation (Bibevski & Dunlap, 2011; Brittenden, Heys, Ross, & Eremin, 1996; Diego, Field, Sanders, & Hernandez-Reif, M., 2004). This is important because… Mindful interventions produce immune system increases and inflammation decreases which can be quantifiably supported by research (Diego, et al., 2004; Zimmerman, 2016). Activation of the parasympathetic nervous system has a cascade of positive health benefits including qualitatively studied mental health benefits which effect physical health. Yoga and tai chi have added physical benefits because they also improve strength, flexibility and balance. Throughout the research, mindful interventions offer mental and physical health protective factors for improved hospital staff performance making them the best choice for mindful programs. 

Hospitals will also need teachers for the interventions. Teachers can be uneducated, inconsistent, expensive, poor quality, hard to find, time-confined, late or they have personality conflicts with students. Lindahl and colleagues (2017) cite poor teachers as a risk factor for adverse effects during mindfulness programs. To rid the program of the teacher problem and expand the opportunity for employee choice and privacy, a different model will be explored.  

Mindful rooms for Phase III. 

Small mindful rooms the size of a large closets will be located on each floor. The number of mindful rooms depends on the number of employees. Sign-up times and reservations will be available online. If the employee is more than one minute late the room is available for another employee to drop-in and use the room. 

The rooms will be equipped with a security camera (for security and to detect unauthorized activity), a viewing screen and a noise blocking headset for audio reception. A yoga mat, bean-bag chair and sanitary wipes for clean-up will be in the room, too. The employee can choose yoga, tai chi, meditation or self-foot/hand/neck massage videos. Providing only one intervention for everyone (Buddhist meditation) was a risk factor for adverse effects in the Lindahl and colleagues study (2017). This venue gives participants the freedom of multiple interventions and multiple teacher choices which increases buy-in and interest as well as decreasing adverse effects (Byron, et al., 2015). All of the video choices will be preselected by the program developer for optimal results.  

Precautions will be taken to address the potential for adverse effects, pointed out in both the Lindahl and colleagues study (2017) and the Von Dam and colleagues study (2018). A warning sign in each room will alert people to the potential hazards of adverse effects. The hospital psychologist’s phone number will be on the sign and the on call psychologist will be available for consultation. 

The hospital will offer employee incentives for time spent in the mindful rooms. For example, 15 minutes of additional vacation time will be accrued for every hour (15-minute increments) spent in the mindful room. Up to four hours per week can be applied to the incentive. Before/after work, lunchtime and breaks can be used. There will be a hospital badge detector to clock in/out at the mindful room door. Privileges will be revoked for unauthorized activity or wrongful clocking in/out. 

Outcome measurements and usage for Phase III. 

The three outcome measurements described in Phase II (the SF36v2 QOL scale, the Turnover Intention Test and the Work Engagement Scale) will be given by the human resources department during new-hire training. The tests will have the same priming statements and anonymity parameters as in Phase II. The tests will be retaken at each staff member’s job evaluation with their supervisor. Most hospitals provide employees a job evaluation meeting with their supervisor once every six months.  

The supervisor will see the QOL scores and can discuss with the staff member why their scores are high or low. If the scores are low, the supervisor can suggest the staff member spends more time in the mindful room. If the supervisor feels the staff member is very low and at risk of quitting his job, the supervisor has the ability to approve the staff member to spend time in the mindful room while he is on the clock. The staff member would be getting paid to be in the mindful room. The large (n=100) Dane and colleagues study (2014) strongly showed mindful interventions reduced job turnover in high turnover occupations, along with four other studies in the job turnover section. As was shown in the literature review studies and in table 1, it is less expensive to pay a hospital staff member to spend time in the mindful room than it is to hire someone new; approximately 86% of one year’s salary (Waldman, et al., 2004).  

If the supervisor notices cynicism growing among his staff group, he will have the authority to assign the entire group to mindful room time while they are on the clock. The individuals can choose their times but it is mandatory, so it must be paid time. Seven studies (Abraham, 2000; Boersma, et al., 2000; Kim, et al., 2009; Luksyte, et al., 2011; Mantler, et al., 2015; Stanley, et al., 2000; Wanous et al., 2000) in this paper’s literature review section discussed the negative effects of cynicism (distrust, pessimism, contempt and frustration toward the organization) on worker time, productivity, effort and (most important to this paper) employee performance. Cynicism is imperative to stop in the workplace. Cynicism leads to expensive job turnover (Dane, et al., 2014; table 1). In this case, the mindful room becomes a constructive and paid disciplinary tool. 

Having a mindful program in place to combat the highly documented detriment of cynicism on hospital staff performance and on high hospital staff turnover is a powerful resolution tool for supervisors. Resolving employee cynicism and hospital turnover increases hospital sustainability potential. 

Costs of Phase III. 

Because mindful programs are easy to administer, show positive results and are low in cost, meta-analysis researchers recommend mindful programs to all healthcare students and healthcare professionals (McConville, McAleer, & Hahne, 2017). The hypothetical literature-based program here is also low in cost due to technology: video teachers, video screens, soundproof audio headsets, automated appointments, hospital badge entry, and security cameras. These items are relatively low in cost compared to hiring additional employees and gym equipment. Additional hospital costs will consist of human resources training, program purchases (videos, power points and process materials), mindful room creation, and room gear (yoga mat and bean-bag chair).  

Opportunities for Home 

The same videos in the mindful rooms will be for sale in the gift shop. Staff members can continue their mindful interventions at home. The Lindahl and colleagues (2017) study found that inconsistent programs and incorrectness of mindful techniques was a risk factor for adverse effects. Offering a way to establish a consistent home program is important to improve healthcare staff performance and decrease adverse effects. 

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